NR 327final maternal exam assured,( do not be left out while the others pass)

Postpartum Hemorrhage (PPH)  From delivery up to 6wks postpartum  SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH) o Estimated blood loss o Quantitative blood loss (weighing everything)  CS C ...

Postpartum Hemorrhage (PPH)  From delivery up to 6wks postpartum  SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH) o Estimated blood loss o Quantitative blood loss (weighing everything)  CS C-Section: greater than 1000ml Two main reasons for PPH  Full bladder  Retained placenta What you will assess when you walk into a patient’s room for PPH 1. Assess Fundus -should always be right at umbilicus If it feels like your cheek: boggy; (massage it) Don’t stop unless it firms up 2. Call for help 3. Call Dr. 4. Meds 5. VS and O2 stat 6. Weigh under pads (add this amount of blood loss to what she lost at delivery 7. Change under pads 8. Empty bladder (foley) 9. Start 2nd IV; may need to give patient blood o Once you start to feel the fundus firm up you can stop massaging o Only thing that can misplace the fundus is a full bladder  The uterus has to contract to stop bleeding Meds (all usually standing orders)  Pitocin: usually IV sometimes IM every patient after they deliver will get this drug (immediately) o If there is a fetus in the uterus; has to be on pump and is piggybacked o If not given wide open  Methergine: given IM; if patient has HTN CANNOT be given this drug  Hemabate: given IM; CANNOT give if patient has asthma (can cause explosive diarrhea)  Cytotec: rectally; given 800-1000 mcg *Methergine and Hemabate: work within 2-3 minutes If all of this doesn’t work then back to the OR  Should be dark brown  Firm w/ Bright red blood- laceration  After delivery check every 15 minutes x 4  Every 30 minutes x 4 1 EXAM 3 Oxygen  8-10L  Non-rebreather mask  Never nasal cannula Menstrual cycle  28, 32, or 36-day cycle  36-day cycle, go back 14 days, she will ovulate on day 22 (can get pregnant on this day)  Have sex on the 17th and the 27th  Ovulation: go back 14 days from very last day of cycle  Sperm lives 3-5 days (200,000,000-800,000,000 per ejaculation)  Ova can only be penetrated for the first 24 hrs  If you want to get pregnant start intercourse 5 days before or 5 days after ovulation  Should have sex every 6 hrs during that time period  Progesterone levels decrease signals hypothalamus to anterior pituitary gland to stimulate the follicle stimulating hormone and luteinizing hormone; which increase estrogen and progesterone (~36 hours)  Corpus luteum: hole where egg left. increases/produces progesterone; you need increase in progesterone to carry a pregnancy  Progesterone levels have to go up in order to hold a pregnancy  Placenta takes over hormone level regulation after 6 - 7 weeks * Naegele’s Rule (estimated due date)  1 st day of last period (minus) 3 months (plus) 7 days -3 months + 7 days 30 days has September, April, June & November 1 st Trimester  Conception – 13 6/7 weeks (13 weeks & 6 days) 2 nd trimester  14 weeks -26 6/7 weeks (26 weeks & 6 days) 3 rd Trimester  27 weeks-40 6/7 weeks (40 weeks & 6 days) Term: 37 weeks or greater 20 weeks gestation when the organs are done being formed G- # of pregnancies T- # of term deliveries P- # of preterm deliveries (20- 36 6/7 weeks) A- # of abortions (less than 20 weeks) 2 EXAM 3 L- # of living children Fetus cannot survive before 20 weeks Antepartum o fetus in uterus Prenatal Visit (1st things that need to be checked)  Vital signs  Estimated Date of Confinement (Estimated Due Date)  Medical hx  CBC  Hep B  HIV  VDRL- STI  Blood type- Rh factor  Rubella titters; drawn at prenatal visit (if nonimmune she needs Rubella titters w/in 72hrs after delivery)  TB skin test  Pap smear  Weight  UA- urinalysis  Fetal heart tones (can be heard at 6 weeks) If mother is Rh-(negative), she needs Rhogam (26-28wks), she needs that because negative antigens may try to fight off pregnancy  If mom is negative and baby blood positive; mom needs Rhogam within 72hrs after delivery to protect next pregnancy *Only run babies cord blood to find out blood type if moms blood type is negative Next visits  VS  Weight  UA  Fetal heart tones  Measure abdomen Office Visits- doctor for normal pregnancies  1 week (conception) - 28 6/7 weeks: o Mom will visit Dr. every 4 weeks  29 weeks- 36 6/7 weeks: o Mom will visit Dr. every 2 weeks  37 weeks and greater: o Mom will visit Dr. every week 3 EXAM 3 Changes in Body Systems: Reproductive  Uterus o F  Cervix o Chadwick signs: bluesish/purplish o Goodell’s sign: cervix softening o Mucus plug: keeps the uterus safe from any germs getting into uterus; can cause some spotting as separating from cervix wall o Hrg’s sign: softening of lower segment of the uterus  Vagina and vulva o Increased vascularity o Vaginal mucosa thickens o Vaginal rugae becomes prominent o Increased roiduction  Breast o Grow larger o Areola gets darker o Colostrum- thick yellow discharge; body getting ready for breast home  Heart  Blood o Blood volume increase o Plasma volume increases: o Cardiac output increase  Relaxin: o body releases during pregnancy; smooth muscle relaxer; keeps BP normal - Has clotting factors in it  Oxygen needs increase o RR will go up about 20%  Appetite o increase after 1st trimester  Mouth o gums may bleed, can get gingivitis, ptyalism  Esophagus o acid reflux; heart burn  Large and small intestines 4 EXAM 3 o everything slows down; constipation (moms need to increase fluid intake and fiber)  Liver and gallbladder o gall stones  Bladder o 1 st and 3rd trimester: frequent urination o 2nd trimester: slows down  Kidneys and ears o formed at the same time: around 16 weeks; if ear is deformed they will look further at the kidney function of the baby  Increase in nutrients in urine o can increase the risk of UTI in mom  Hair and nails o grow rapid and thicker  Ear o cornea becomes thicker o diminished hearing; increased wax  Autoimmune conditions o decrease during pregnancy o after pregnancy condition becomes worst  Pituitary gland o Prolactin o Oxytocin: after 36 weeks oxytocin levels go up progesterone starts to go down *Normal for pregnant women to have a trace of glucose in urine o Moms become insulin resistant to make more glucose for baby Conformation of pregnancy:  Presumptive (subjective) o Amenorrhea o N/V o Fatigue o Urinary frequency o Breast changes o Vaginal & cervical color changes 5 EXAM 3 o Quickening (fetal movement)- flutter of gas  Probable (objective) o Abdominal enlargement o Goodell’s sign softening of the lower part of the cervix-soft like your cheek. o Hagar’s sign (softening of the lower uterine segment) o Ballottement- Dr. does a dig vag exam & can push up on cervix. Fetus will go up & come back down o Braxton Hicks pre-contractions ATI o Palpation of fetal outline- Enlarged abdomen o Positive pregnancy test o Chadwick sign-- bluish purple color of the cervix  Positive o Fetal heart sounds o Fetal movement detected by provider o Visualization of the embryo or fetus First Trimester  Uncertainty Second Trimester  Physical evidence of pregnancy  Fetus as the primary  Narcissism and introversion  Body image  Changes in sexuality; changes in sex drive Third Trimester  Vulnerability  Increasing dependence  Preparation for birth o Nesting behavior (happen later on; just before labor) Maternal Role Transition  Three stages of attachment o Accepts pregnancy o Baby becomes real; she loves it o Increasing love and vulnerability; mom will do anything she has to do Couvade: where the father goes through the same symptoms as the mom 6 EXAM 3  Things to know: o Mom needs 600mcg/day of folic acid o Mom: needs extra calcium o hCG: levels go up when pregnant o Moms should gain 25-35lbs: normal weight gain o Should drink 6-8liters/day o DO NOT ovulate during pregnancy o Never lie a pregnant women supine/flat on back; always needs to have a pillow wedged behind her back Week 2 Notes Effects of the birth process: Maternal Response Variability- (goes up & down) when we look at a fetal monitor strip. We’re always going to look for variability It’s the babies hear beat from beat to beat Absent- 0 BPM Minimal 0-5 BPM Moderate 5-25 BPM—Always want Marked >25 BPM Characteristics of contractions:  Coordinated o Frequency  Beginning of one uterine contraction to the beginning of the next  Range in minutes; how often (ex. 1.5- 2 minutes)  Don’t want a frequeny to be any more than 2 min’s lasting about 60-90 sec’s o Duration  Beginning of a uterine contraction to the end of the same contraction when it comes back to baseline  Range in seconds; how long is last (ex. 60-90 sec’s)  Involuntary  Intermittent- relaxation of the contraction (we must have this relaxation period, because if not. That means the uterus is not contracting & it’s where the fetus is getting most nutrients & oxygen. During that resting tone) Contraction Cycle o Increment  Period of increasing strength o Acme  Period during which the contraction is most intense 7 EXAM 3 o Decrement  Period of decreasing intensity as the uterus relaxes *In-between contractions is where baby gets it oxygen and blood supply that is being sent through the umbilical cord. Want contractions to be about 2 mins apart lasting 60- 90 secs Skinniest to fattest.. shortest to longest.. contraction Fetal Heart Tones  Baseline o Where the baby’s heart rate hits the most  Accelerations  Decelerations o Variable o Early- head compression- close to delivery- they mirror the contractions o Late Variability: BPM (beats per minute)- V Shape or W shape  0-5: absent -minimal  5-25: moderate (what we want)  >25: marked  3 Ss (reasons for absent to moderate variability will vary) o Sleeping o Sedated- mom may have been given fentanyl or stadol or any narcotic o Sick (neonates temp will drop) If baby is not any of these- notify HCP Fetal Heart strip  Baby heart tone always at top  Mom contractions at the bottom Variable (type of deceleration) Cord Compression -Sudden drop with a quick return to baseline -Reposition mom w/in 30 seconds. V or W appearance Early (starts right w/contraction) Head Compression (usually est. 8cm) -mirrors mom contraction -Sterile vaginal exam (find out dilation) - reposition mom Acceleration (above baseline)-lack of baseline Oxygenated -Baby is saying he is ok 8 EXAM 3 Late (declaration and contraction don’t match) Placental insufficiency -Baby suffering -Not getting enough oxygen & nutrients Characteristics of late- beginning, middle, & end are off LATE deceleration (what to do) 1. Reposition mom 2. Shut off Pitocin (causes contractions) 3. Increase IV fluids 4. o2 via nonrebreather mask (8-10/L) 5. Sterile vaginal exam6. Call provider *Anything goes below baseline; deceleration *Want to see lots & lots of acceleration (when baby moves HR should go up) *NEVER nasal cannula in L&D Accelerated Increase in fetal heart rate  15 beats by 15 beats above baseline (32+weeks)  10 beats by 10 beats above baseline (under 32 weeks) Fetus well oxygenated Uterine body  Upper two thirds of the uterus contracts actively to push fetus down  Lower one third remains less active Cervical changes  Effacement (thinning and shortening: cervix)  Dilation (opening)  Effacement and dilation occur concurrently during labor bur at different rates *the only soft tissue that can hold a baby up from delivering is a full bladder Placental circulation  Most placenta exchange occurs during the interval b/w contractions Components of the Birth Process Five major factors that interact 9 EXAM 3  Powers o Contractions o Maternal pushing  Passage o Pelvis  Passenger o Baby o Placenta o Membranes Baby can’t come out if it’s extended or hyperextended  Psyche (how mom feels about pushing) o Anxiety o Culture and expectation o Birth as an experience o Support o Impact of technology  Position o Fetal head position o Want baby to be in an anterior position (occipital) OA o OT- occipital transverse Presentation  Fetal part that first enters the pelvis  Cephalic o Vertex, military, brow, face  Breech o Frank, full, footling  Shoulder  Cephalic Presentation  The cephalic presentation is more favorable than others for the following reasons:  • The fetal head is the largest single fetal part, although the breech (buttocks), with the legs and feet flexed on the abdomen, is collectively larger than the head. After the head is born, the smaller parts follow easily as the extremities unfold.  • During labor, the fetal head can gradually change shape, molding to adapt to the size and shape of the maternal pelvis.  • The fetal head is smooth, round, and hard, making it a more effective part to dilate the cervix, which is also round.  Cephalic presentation has the following four variations (Fig. 12.8):  • Vertex—This is the most common type of cephalic presentation, in which the fetal head is fully flexed. It is called a vertex or occiput presentation and is the most favorable for normal progress of labor because the smallest suboccipitobregmatic diameter is presenting.  • Military—The head is in a neutral position, neither flexed nor extended. The longer occipitofrontal diameter is presenting.  • Brow—The fetal head is partly extended. The brow presentation is unstable, usually converting to a vertex presentation if the head flexes or to a face presentation if it extends. The longest supraoccipitomental diameter is presenting. C-section  • Face—The head is extended, and the fetal occiput is near the fetal spine. The submentobregmatic diameter is presenting. C-section